But predicting which villages are at risk is challenging. What health experts really need to know is where the bats go at night to better understand how the virus is transmitted to humans. To answer that question, CDC scientists have spearheaded a small pilot project with Ugandan experts to put GPS units on the backs of bats to track their movements. It’s wild work but the risk will have been worth it if the information they get can help shed light on where the bats are going and how they get there. Operating a mobile lab in a remote jungle has its challenges, not to mention monkeys- lots of them. In the heart of Queen Elizabeth National Park, scientists trail through one and a half kilometers of terrain to reach the entrance of the cave as nearby hippos, elephants and zebras take notice. Besides bats, Python Cave is full of sharp rocks, ants, ticks, and-of course-snakes. So scientists must wear head-to-toe protective gear to safely work under these conditions. One by one, these wing flapping mammals are captured in fabric bags. Back at the mobile lab, scientists carefully glue a small GPS unit onto the bat’s backs, in a place that doesn’t interfere with their ability to fly.The bats are then released to go back to the cave. When evening falls, the magic begins. As the bats fly out to forage, their routes are tracked by satellite.

The project at Python Cave has shown that some bats fly dozens of miles in a single night and visit other local caves. Scientists hope that the information from this project will help better predict which areas are most at risk for Marburg, so the next outbreak can be stopped before it ever starts.

“…..H. longicornis is native to eastern China, Japan, the Russian Far East, and Korea. It is an introduced, and now established, exotic species in Australia, New Zealand, and several island nations in the western Pacific Region. Where this tick exists, it is an important vector of human and animal disease agents. In China and Japan, it transmits the severe fever with thrombocytopenia syndrome virus (SFTSV), which causes a human hemorrhagic fever (2), and Rickettsia japonica, which causes Japanese spotted fever…..”

Counties and county equivalents* where Haemaphysalis longicornis has been reported (N = 45) — United States, August 2017–September 2018

Distribution of Haemaphysalis longicornis, by host and species — nine states, August 2017–September 2018

The World Health Organization R&D Blueprint aims to accelerate the availability of medical technologies during epidemics by focusing on a list of prioritized emerging diseases for which medical countermeasures are insufficient or nonexistent. The prioritization process has 3 components: a Delphi process to narrow down a list of potential priority diseases, a multicriteria decision analysis to rank the short list of diseases, and a final Delphi round to arrive at a final list of 10 diseases.

A group of international experts applied this process in January 2017, resulting in a list of 10 priority diseases. The robustness of the list was tested by performing a sensitivity analysis. The new process corrected major shortcomings in the pre–R&D Blueprint approach to disease prioritization and increased confidence in the results.

2018 annual review of the Blueprint list of priority diseases

For the purposes of the R&D Blueprint, WHO has developed a special tool for determining which diseases and pathogens to prioritize for research and development in public health emergency contexts. This tool seeks to identify those diseases that pose a public health risk because of their epidemic potential and for which there are no, or insufficient, countermeasures. The diseases identified through this process are the focus of the work of R& D Blueprint. This is not an exhaustive list, nor does it indicate the most likely causes of the next epidemic.

February 2018 – Second annual review

The second annual review occurred 6-7 February, 2018. Experts consider that given their potential to cause a public health emergency and the absence of efficacious drugs and/or vaccines, there is an urgent need for accelerated research and development for*:

Disease X represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease, and so the R&D Blueprint explicitly seeks to enable cross-cutting R&D preparedness that is also relevant for an unknown “Disease X” as far as possible.

A number of additional diseases were discussed and considered for inclusion in the priority list, including: Arenaviral hemorrhagic fevers other than Lassa Fever; Chikungunya; highly pathogenic coronaviral diseases other than MERS and SARS; emergent non-polio enteroviruses (including EV71, D68); and Severe Fever with Thrombocytopenia Syndrome (SFTS).

These diseases pose major public health risks and further research and development is needed, including surveillance and diagnostics. They should be watched carefully and considered again at the next annual review. Efforts in the interim to understand and mitigate them are encouraged.

Although not included on the list of diseases to be considered at the meeting, monkeypox and leptospirosis were discussed and experts stressed the risks they pose to public health. There was agreement on the need for: rapid evaluation of available potential countermeasures; the establishment of more comprehensive surveillance and diagnostics; and accelerated research and development and public health action.

Several diseases were determined to be outside of the current scope of the Blueprint: dengue, yellow fever, HIV/AIDs, tuberculosis, malaria, influenza causing severe human disease, smallpox, cholera, leishmaniasis, West Nile Virus and plague. These diseases continue to pose major public health problems and further research and development is needed through existing major disease control initiatives, extensive R&D pipelines, existing funding streams, or established regulatory pathways for improved interventions. In particular, experts recognized the need for improved diagnostics and vaccines for pneumonic plague and additional support for more effective therapeutics against leishmaniasis.

The experts also noted that:

For many of the diseases discussed, as well as many other diseases with the potential to cause a public health emergency, there is a need for better diagnostics.

Existing drugs and vaccines need further improvement for several of the diseases considered but not included in the priority list.

Any type of pathogen could be prioritised under the Blueprint, not only viruses.

Necessary research includes basic/fundamental and characterization research as well as epidemiological, entomological or multidisciplinary studies, or further elucidation of transmission routes, as well as social science research.

There is a need to assess the value, where possible, of developing countermeasures for multiple diseases or for families of pathogens.

The impact of environmental issues on diseases with the potential to cause public health emergencies was discussed. This may need to be considered as part of future reviews.

The importance of the diseases discussed was considered for special populations, such as refugees, internally displaced populations, and victims of disasters.

The value of a One Health approach was stressed, including a parallel prioritization processes for animal health. Such an effort would support research and development to prevent and control animal diseases minimising spill-over and enhancing food security. The possible utility of animal vaccines for preventing public health emergencies was also noted.

Also there are concerted efforts to address anti-microbial resistance through specific international initiatives. The possibility was not excluded that, in the future, a resistant pathogen might emerge and appropriately be prioritized.

*The order of diseases on this list does not denote any ranking of priority.

The Government of the Democratic Republic of the Congo declared a new outbreak of Ebola virus disease (EVD) in Bikoro in Equateur Province today (8 May). The outbreak declaration occurred after laboratory results confirmed two cases of EVD.

The Ministry of Health of Democratic of the Congo (DRC) informed WHO that two out of five samples collected from five patients tested positive for EVD at the Institut National de Recherche Biomédicale (INRB) in Kinshasa. More specimens are being collected for testing.

WHO is working closely with the Government of the DRC to rapidly scale up its operations and mobilize health partners using the model of a successful response to a similar EVD outbreak in 2017.

“Our top priority is to get to Bikoro to work alongside the Government of the Democratic Republic of the Congo and partners to reduce the loss of life and suffering related to this new Ebola virus disease outbreak,” said Dr Peter Salama, WHO Deputy Director-General, Emergency Preparedness and Response. “Working with partners and responding early and in a coordinated way will be vital to containing this deadly disease.”

The first multidisciplinary team comprised of experts from WHO, Médecins Sans Frontières and Provincial Division of Health travelled today to Bikoro to strengthen coordination and investigations.

Bikoro is situated in Equateur Province on the shores of Lake Tumba in the north-western part of the country near the Republic of the Congo. All cases were reported from iIkoko Iponge health facility located about 30 kilometres from Bikoro. Health facilities in Bikoro have very limited functionality, and rely on international organizations to provide supplies that frequently stock out.

“We know that addressing this outbreak will require a comprehensive and coordinated response. WHO will work closely with health authorities and partners to support the national response. We will gather more samples, conduct contact tracing, engage the communities with messages on prevention and control, and put in place methods for improving data collection and sharing,” said Dr Matshidiso Moeti, the WHO Regional Director for Africa.

This is DRC’s ninth outbreak of EVD since the discovery of the virus in the country in 1976. In the past five weeks, there have been 21 suspected viral haemorrhagic fever in and around the iIkoko Iponge, including 17 deaths.

“WHO is closely working with other partners, including Médecins Sans Frontières, to ensure a strong, response to support the Government of the Democratic Republic of the Congo to prevent and control the spreading of the disease from the epicentre of iIkoko Iponge Health Zone to save lives,” said Dr Allarangar Yokouide, WHO Representative in the DRC.

Upon learning about the laboratory results today, WHO set up its Incident Management System to fully dedicate staff and resources across the organization to the response. WHO plans to deploy epidemiologists, logisticians, clinicians, infection prevention and control experts, risk communications experts and vaccination support teams in the coming days. WHO will also be determining supply needs and help fill gaps, such as for Personal Protective Equipment (PPE). WHO has also alerted neighbouring countries.

WHO released US$ 1 million from its Contingency Fund for Emergencies to support response activities for the next three months with the goal of stopping the spread of Ebola to surrounding provinces and countries.

Building on the 2017 response

Ebola is endemic to the Democratic Republic of the Congo. The last Ebola outbreak in the Democratic Republic of the Congo occurred in 2017 in Likati Health Zone, Bas Uele Province, in the northern part of the country and was quickly contained thanks to joint efforts by the Government of DRC, WHO and many different partners.

An effective response to the 2017 EVD outbreak was achieved through the timely alert by local authorities of suspect cases, immediate testing of blood samples due to strengthened national laboratory capacity, the early announcement of the outbreak by the government, rapid response activities by local and national health authorities with the robust support of international partners, and speedy access to flexible funding.

Coordination support on the ground by WHO was critical and an Incident Management System was set up within 24 hours of the outbreak being announced. WHO deployed more than 50 experts to work closely with government and partners.

The Ebola virus causes an acute, serious illness which is often fatal if untreated. The average EVD case fatality rate is around 50%. The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.

CDC/ Conrad: This type of maculopapular rash, which can appear on Marburg patients around the fifth day after the onset of symptoms, usually may be found on the patient’s chest, back and stomach. This patient’s skin blanched under pressure, which is a common characteristic of a Marburg virus rash.

Updated October 2017

Key facts

Marburg virus disease (MVD), formerly known as Marburg haemorrhagic fever, is a severe, often fatal illness in humans.

Rousettus aegyptiacus, fruit bats of the Pteropodidae family, are considered to be natural hosts of Marburg virus. The Marburg virus is transmitted to people from fruit bats and spreads among humans through human-to-human transmission.

The Marburg virus causes severe viral haemorrhagic fever in humans.

The average MVD case fatality rate is around 50%. Case fatality rates have varied from 24% to 88% in past outbreaks depending on virus strain and case management.

Community engagement is key to successfully controlling outbreaks. Good outbreak control relies on applying a package of interventions, namely case management, infection prevention and control practices, surveillance and contact tracing, a good laboratory service, safe burials and social mobilization.

Early supportive care with rehydration, symptomatic treatment improves survival. There is as yet no licensed treatment proven to neutralize the virus but a range of blood products, immune therapies and drug therapies are currently under development.

Marburg virus is the causative agent of Marburg virus disease (MVD), a disease with a case fatality ratio of up to 88%. Marburg virus disease was initially detected in 1967 after simultaneous outbreaks in Marburg and Frankfurt in Germany; and in Belgrade, Serbia.

Marburg and Ebola viruses are both members of the Filoviridae family (filovirus). Though caused by different viruses, the two diseases are clinically similar. Both diseases are rare and have the capacity to cause dramatic outbreaks with high fatality rates.

Two large outbreaks that occurred simultaneously in Marburg and Frankfurt in Germany, and in Belgrade, Serbia, in 1967, led to the initial recognition of the disease. The outbreak was associated with laboratory work using African green monkeys (Cercopithecus aethiops) imported from Uganda. Subsequently, outbreaks and sporadic cases have been reported in Angola, Democratic Republic of the Congo, Kenya, South Africa (in a person with recent travel history to Zimbabwe) and Uganda. In 2008, two independent cases were reported in travelers who had visited a cave inhabited by Rousettus bat colonies in Uganda.

Transmission

Marburg spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

Health-care workers have frequently been infected while treating patients with suspected or confirmed MVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced. Transmission via contaminated injection equipment or through needle-stick injuries is associated with more severe disease, rapid deterioration, and, possibly, a higher fatality rate.

Burial ceremonies that involve direct contact with the body of the deceased can also contribute in the transmission of Marburg.

People remain infectious as long as their blood contains the virus.

Sexual transmission

Marburg virus transmission via infected semen has been documented up to seven weeks after clinical recovery. More surveillance data and research are needed on the risks of sexual transmission, and particularly on the prevalence of viable and transmissible virus in semen over time. In the interim, and based on present evidence, WHO recommends that:

All Marburg survivors and their sexual partners should receive counselling to ensure safer sexual practices until their semen has twice tested negative for Marburg virus.

Survivors should be provided with condoms.

Male Marburg survivors should be enrolled in semen testing programmes when discharged (starting with counselling) and offered semen testing when mentally and physically ready, within three months of disease onset.

Marburg survivors and their sexual partners should either:

abstain from all sexual practices, or

observe safer sexual practices through correct and consistent condom use until their semen has twice tested undetected ( negative) for Marburg virus.

Male survivors of Marburg virus disease should practice safer sexual practices and hygiene for 12 months from onset of symptoms or until their semen twice tests undetected (negative) for Marburg virus.

Until such time as their semen has twice tested undetected (negative) for Marburg, survivors should practice good hand and personal hygiene by immediately and thoroughly washing with soap and water after any physical contact with semen, including after masturbation. During this period used condoms should be handled safely, and safely disposed of, so as to prevent contact with seminal fluids.

All survivors, their partners and families should be shown respect, dignity and compassion.

Symptoms of Marburg virus disease

The incubation period (interval from infection to onset of symptoms) varies from 2 to 21 days.

Illness caused by Marburg virus begins abruptly, with high fever, severe headache and severe malaise. Muscle aches and pains are a common feature. Severe watery diarrhoea, abdominal pain and cramping, nausea and vomiting can begin on the third day. Diarrhoea can persist for a week. The appearance of patients at this phase has been described as showing “ghost-like” drawn features, deep-set eyes, expressionless faces, and extreme lethargy. In the 1967 European outbreak, non-itchy rash was a feature noted in most patients between 2 and 7 days after onset of symptoms.

Many patients develop severe haemorrhagic manifestations between 5 and 7 days, and fatal cases usually have some form of bleeding, often from multiple areas. Fresh blood in vomitus and faeces is often accompanied by bleeding from the nose, gums, and vagina. Spontaneous bleeding at venepuncture sites (where intravenous access is obtained to give fluids or obtain blood samples) can be particularly troublesome. During the severe phase of illness, patients have sustained high fevers. Involvement of the central nervous system can result in confusion, irritability, and aggression. Orchitis (inflammation of one or both testicles) has been reported occasionally in the late phase of disease (15 days).

In fatal cases, death occurs most often between 8 and 9 days after symptom onset, usually preceded by severe blood loss and shock.

Persistent virus in people recovering from Marburg virus disease

Marburg virus is known to persist in immune-privileged sites in some people who have recovered from Marburg virus disease. These sites include the testicles and the inside of the eye.

In women who have been infected while pregnant, the virus persists in the placenta, amniotic fluid and fetus.

In women who have been infected while breastfeeding, the virus may persist in breast milk.

Relapse-symptomatic illness in the absence of re-infection in someone who has recovered from MVD is a rare event, but has been documented. Reasons for this phenomenon are not yet fully understood.

Diagnosis

It can be difficult to clinically distinguish MVD from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers. Confirmation that symptoms are caused by Marburg virus infection are made using the following diagnostic methods:

antibody-capture enzyme-linked immunosorbent assay (ELISA)

antigen-capture detection tests

serum neutralization test

reverse transcriptase polymerase chain reaction (RT-PCR) assay

electron microscopy

virus isolation by cell culture.

Samples collected from patients are an extreme biohazard risk; laboratory testing on non-inactivated samples should be conducted under maximum biological containment conditions. All biological specimens should be packaged using the triple packaging system when transported nationally and internationally.

Treatment and vaccines

Supportive care – rehydration with oral or intravenous fluids – and treatment of specific symptoms, improves survival. There is as yet no proven treatment available for MVD. However, a range of potential treatments including blood products, immune therapies and drug therapies are currently being evaluated.

Marburg virus in animals

Rousettus aegyptiacus bats are considered natural hosts for Marburg virus. There is no apparent disease in the fruit bats. As a result, the geographic distribution of Marburg virus may overlap with the range of Rousettus bats.

African green monkeys (Cercopithecus aethiops) imported from Uganda were the source of infection for humans during the first Marburg outbreak.

Experimental inoculations in pigs with different Ebola viruses have been reported and show that pigs are susceptible to filovirus infection and shed the virus. Therefore pigs should be considered as a potential amplifier host during MHF outbreaks. Although no other domestic animals have yet been confirmed as having an association with filovirus outbreaks, as a precautionary measure they should be considered as potential amplifier hosts until proven otherwise.

Precautionary measures are needed in pig farms in Africa to avoid pigs becoming infected through contact with fruit bats. Such infection could potentially amplify the virus and cause or contribute to MHF outbreaks.

Prevention and control

Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe and dignified burials, and social mobilization. Community engagement is key to successfully controlling outbreaks. Raising awareness of risk factors for Marburg infection and protective measures that individuals can take is an effective way to reduce human transmission.

Risk reduction messaging should focus on several factors:

Reducing the risk of bat-to-human transmission arising from prolonged exposure to mines or caves inhabited by fruit bat colonies. During work or research activities or tourist visits in mines or caves inhabited by fruit bat colonies, people should wear gloves and other appropriate protective clothing (including masks). During outbreaks all animal products (blood and meat) should be thoroughly cooked before consumption.

Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their body fluids. Close physical contact with Marburg patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing should be performed after visiting sick relatives in hospital, as well as after taking care of ill patients at home.

Communities affected by Marburg should make efforts to ensure that the population is well informed, both about the nature of the disease itself and about necessary outbreak containment measures.

Outbreak containment measures include prompt and safe burial of the dead, identifying people who may have been in contact with someone infected with Marburg and monitoring their health for 21 days, separating the healthy from the sick to prevent further spread, and maintaining good hygiene and a clean environment need to be observed.

Reducing the risk of possible sexual transmission. Based on further analysis of ongoing research, WHO recommends that male survivors of Marburg virus disease practice safe sex and hygiene for 12 months from onset of symptoms or until their semen twice tests negative for Marburg virus. Contact with body fluids should be avoided and washing with soap and water is recommended. WHO does not recommend isolation of male or female convalescent patients whose blood has been tested negative for Marburg virus.

Controlling infection in healthcare settings

Healthcare workers should always take standard precautions when caring for patients, regardless of their presumed diagnosis. These include basic hand hygiene, respiratory hygiene, use of personal protective equipment (to block splashes or other contact with infected materials), safe injection practices and safe and dignified burial practices.

Healthcare workers caring for patients with suspected or confirmed Marburg virus should apply extra infection control measures to prevent contact with the patient’s blood and body fluids and contaminated surfaces or materials such as clothing and bedding. When in close contact (within 1 metre) of patients with MVD, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures).

Laboratory workers are also at risk. Samples taken from humans and animals for investigation of Marburg infection should be handled by trained staff and processed in suitably equipped laboratories.

WHO response

WHO aims to prevent Marburg outbreaks by maintaining surveillance for Marburg virus disease and supporting at-risk countries to develop preparedness plans. The following document provides overall guidance for control of Ebola and Marburg virus outbreaks:

When an outbreak is detected WHO responds by supporting surveillance, community engagement, case management, laboratory services, contact tracing, infection control, logistical support and training and assistance with safe burial practices.

WHO has developed detailed advice on Marburg infection prevention and control:

8 December 2017 | Geneva – Uganda has successfully controlled an outbreak of Marburg virus disease and prevented its spread only weeks after it was first detected, the World Health Organization said on Friday (December 8).

“Uganda has led an exemplary response. Health authorities and partners, with the support of WHO, were able to detect and control the spread of Marburg virus disease within a matter of weeks,” said Dr Matshidiso Moeti, WHO Regional Director for Africa.

The Ugandan Ministry of Health notified WHO of the outbreak on October 17, after laboratory tests confirmed that the death of a 50-year-old woman was due to infection with the Marburg virus. A Public Health Emergency Operations Centre was immediately activated and a national taskforce led the response.

Three people died over the course of the outbreak which affected two districts in eastern Uganda near the Kenyan border, Kween and Kapchorwa. Health workers followed up with a total 316 close contacts of the patients in Uganda and Kenya to ensure that they had not acquired the illness.

The MVD outbreak was declared contained by the Ministry of Health after the contacts of the last confirmed patient completed 21 days of follow up (to account for the 21-day incubation period of the virus) and an additional 21 days of intensive surveillance was completed in affected districts.

“As evidenced by the quick and robust response to the Marburg virus disease outbreak, we are committed to protecting people by ensuring that all measures are in place for early detection and immediate response to all viral haemorrhagic fever outbreaks,” said Ugandan Minister of Health Sarah Opendi.

Within 24 hours of being informed by Ugandan health authorities in early October, WHO deployed a rapid response team to the remote mountainous area. The Organization also released US$623,000 from its Contingency Fund for Emergencies (CFE) to finance immediate support and scale up of the response in Uganda and Kenya.

In subsequent weeks, WHO and partners supported laboratory testing and surveillance, the search for new cases and their contacts, establishing infection prevention measures in health facilities, managing and treating cases, and engaging with communities.

Surveillance and contact tracing on the Kenyan side of the border by the Kenyan Ministry of Health and partners also prevented cross-border spread of the disease.

“The response to the Marburg virus disease outbreak demonstrates how early alert and response, community engagement, strong surveillance and coordinated efforts can stop an outbreak in its tracks before it ravages communities,” said Dr. Peter Salama, Executive Director of the WHO Health Emergencies Programme. “This was Uganda’s fifth MVD outbreak in ten years. We need to be prepared for the next one.”

WHO will continue to support health authorities in both countries to upgrade their surveillance and response capabilities – including infection prevention and control measures, and case management.

Note to editors

The response to the Marburg virus disease outbreak was led by health authorities in Uganda and Kenya in coordination with the World Health Organization (WHO), the Global Outbreak Alert and Response Network (GOARN), the US Centers for Disease Control and Prevention (CDC), the African Field Epidemiology Network (AFENET), UNICEF, Médecins Sans Frontières (MSF), the International Federation of Red Cross and Red Crescent Societies (IFRC), the International Committee of the Red Cross (ICRC), the Uganda Red Cross Society, the European Union Commission’s Civil Protection Mechanism and the Emergency Response Coordination Centre (ECHO-ERCC), the Bernhard Nocht Institute for Tropical Medicine and Marburg University in Germany, the European Union Mobile Lab Consortium and the Alliance for International Medical Action (ALIMA), the Uganda Virus Research Institute (UVRI), the Joint Mobile Emerging Diseases Intervention Clinical Capability (JMEDICC), the Infectious Diseases Institute of Makarere University (IDI), the Kenya Red Cross Society, and the Kenya Medical Research Institute (KEMRI).

On 17 October 2017, the Ugandan Ministry of Health notified WHO of a confirmed outbreak of Marburg virus disease in Kween District, Eastern Uganda. The Ministry for Health officially declared the outbreak on 19 October 2017.

As of 24 October, five cases have been reported – one confirmed case, one probable case with an epidemiological link to the confirmed case, and three suspected cases including two health workers.

Chronologically, the first case-patient (probable case) reported was a male in his 30s, who worked as a game hunter and lived near a cave with a heavy presence of bats. On 20 September, he was admitted to a local health centre with high fever, vomiting and diarrhoea, and did not respond to antimalarial treatment. As his condition deteriorated, he was transferred to the referral hospital in the neighbouring district, where he died the same day. No samples were collected. He was given a traditional burial, which was attended by an estimated 200 people.

The sister (confirmed case) of the first case-patient nursed him and participated in the burial rituals. She became ill and was admitted to the same health centre on 5 October 2017 with fever and bleeding manifestations. She was subsequently transferred to the same referral hospital, where she died. She was given a traditional burial. Posthumous samples were collected and sent to the Uganda Virus Research Institute (UVRI). On 17 October, Marburg virus infection was confirmed at UVRI by RT-PCR and it was immediately notified to the Ministry of Health.

The third case-patient (suspected case) is the brother of the first two cases. He assisted in the transport of his sister to the hospital, and subsequently became symptomatic. He refused to be admitted to hospital, and returned to the community. His whereabouts are currently not known though there is an ongoing effort to find him.

Two health workers who were in contact with the confirmed case have developed symptoms consistent with Marburg virus disease and are under investigation (suspected cases). Laboratory results to rule out Marburg virus disease are pending.

Contact tracing and follow-up activities have been initiated. As of 23 October, 155 contacts including 66 who had contact with the first case and 89 who had contact with the second case-patient have been listed in the two affected districts, including 44 health care workers. The number of family and community contacts is still being investigated.

Public health response

The Ugandan Ministry of Health has rapidly responded to the outbreak, with support from WHO and partners. A rapid response field team was deployed to the two affected districts within 24 hours of the confirmation.

To coordinate response activities, the National Task Force has convened, an Incident Management System (IMS) framework implemented with an Incident Manager appointed, a District Task Force has been established, and an emergency rapid response plan has been developed.

Marburg virus disease response activities have been initiated, including surveillance, active case search, contact tracing and follow-up, as well as monitoring within affected communities and healthcare centres.

Personal protective equipment has been deployed in the affected districts. Healthcare workers have been put on high alert and training sessions are planned, including a thorough review of infection prevention and control (IPC) protocols and capacity. An isolation facility is being prepared at the health centre and the hospital.

Training of teams for safe and dignified burials has been conducted in affected districts.

Community engagement and awareness campaigns are ongoing to reduce stigma, encourage reporting and early healthcare seeking behaviours, and acceptance of prevention measures. Information, education and communication materials and messages have been updated and are being produced.

International partners and stakeholders have been engaged at country level, and internationally to provide support and technical assistance for the response as needed. WHO has deployed additional staff, and six viral haemorrhagic fever (VHF) kits. Funding has been provided from the WHO Contingency Fund for Emergencies to ensure immediate support and scale up the response. WHO has alerted partners in the Global Outbreak Alert and Response Network (GOARN), and is coordinating international support for the response.

UNICEF is assisting with communication activities, and community engagement.

Médecins Sans Frontières has deployed to support setting up of treatment centres.

As of 24 October, five cases have been identified – one confirmed case, one probable case, and three suspected cases, and the outbreak remains localised. Ugandan health authorities have responded rapidly to this event, and measures are being rapidly implemented to control the outbreak. The high number of potential contacts in extended families, at healthcare facilities and surrounding traditional burial ceremonies is a challenge for the response. In addition, hospitalised cases were handled in general wards without strict infection control precautions, and one probable case refused to be hospitalised for a period of time.

The affected districts are in a rural, mountainous area located on the border with Kenya, about 300km northeast of Kampala on the northern slopes of Mount Elgon National Park. The Mount Elgon caves are a major tourist attraction, and are host to large colonies of cave-dwelling fruit bats, known to transmit the Marburg virus. The close proximity of the affected area to the Kenyan border, and cross-border movement between the affected district and Kenya and the potential transmission of the virus between colonies and to humans, increases the risk of cross-border spread.

These factors suggest a high risk at national and regional level, requiring an immediate, coordinated response with support from international partners. Tourism to Mount Elgon including the caves and surrounding areas should be noted and appropriate advice given and precautions taken. The risk associated with the event at the global level is low.

WHO advice

Human-to-human transmission of Marburg virus is primarily associated with direct contact with blood and body fluids, and Marburg virus transmission associated with provision of health care has been reported when appropriate infection control measures have not been observed.

Health-care workers caring for patients with suspected or confirmed Marburg virus should apply infection control precautions to avoid any exposure to blood and body fluids, and unprotected contact with possibly contaminated environment.

Surveillance activities, including contact tracing and active case search must be strengthened within all affected health zones.

Raising awareness of the risk factors for Marburg infection and the protective measures individuals can take to reduce human exposure to the virus, are the key measures to reduce human infections and deaths. Key public health communication messages include:

Reducing the risk of bat-to-human transmission arising from prolonged exposure to mines or caves inhabited by fruit bats colonies. During work or research activities or tourist visits in mines or caves inhabited by fruit bat colonies, people should wear gloves and other appropriate protective clothing (including masks).

Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their body fluids. Close physical contact with Marburg patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing should be performed after visiting sick relatives in hospital, as well as after taking care of ill patients at home.

Communities affected by Marburg should make efforts to ensure that the population is well informed, both about the nature of the disease itself to avoid community stigmatization, and encourage early presentation to treatment centres and other necessary outbreak containment measures, including burial of the dead. People who have died from Marburg should be promptly and safely buried.

WHO advises against the application of any travel or trade restrictions on Uganda or the affected area based on the current information available on this event. Travellers to the Mount Elgon bat caves are advised to avoid exposure to bats and contact with non-human primates, and, to the extent possible, to wear gloves and protecting clothing, including masks .

For further information on Marburg virus disease and prevention and control measures is available in the WHO Marburg virus disease factsheet.

Uganda Virus Research Institute has confirmed cases of the deadly Marburg virus in Kween District on the western slopes of Mt. Elgon in Eastern Uganda. Two people have died from the deadly hemorrhagic fever.

The Ministry of health is sending an emergency response team to the district.